List of common abbreviations used in medical notes
PC
HPC
PMH
PSH
PPH
presenting complaint
history of the PC
past medical history
past surgical history
past psychiatric history
Drug history (prescribed
DH
OTC (bought over the counter, allergies)
FH
family history
SH
social history
SE
systemic enquiry
 frequently used interchangeably
ODQ
on direct questioning

SOBOE
shortness of breath on exertion
PND
paroxysmal nocturnal dyspnoea
BOR
bowels opening regularly
PU
passing urine
SI
sexual intercourse
TOP
termination of pregnancy (i.e a surgical or medical abortion)
K=4/26menstrual cycle – period lasts for 4 days, coming on every
30
26 to 30 days
G4P3+1
(pronounced “gravida 4 para 3 plus 1”) – a woman who has been
pregnant (“gravid”) four times, and had 3 pregnancies (‘para’)
proceeding beyond the 28th week. The ‘+1’ means she
has had a
pregnancy of less than 28 weeks (perhaps
ending in a TOP or
miscarriage).
1/7, 12/7
one day, twelve days (7 = days in a week)
3/52, 5/52
three weeks, five weeks (52 = weeks in a year)
2/12, 8/12
two months, eight months (12 = months in a year)
C4/7 etc
around four days etc
VV
varicose veins
General Examination
OE
on examination
T
temperature
P
pulse
BP
blood pressure
R
respiration rate
J
jaundice
TB
tuberculosis
Cy
cyanosis
°J, °Cy no jaundice, no cyanosis
CVS Cardiovascular System
5ICSMCL
HS
PSM
JVP
JVP15cm
PP
5th intercostals space, mid-clavicular line (the normal place for feeling
the cardiac apical beat)
heart sounds
pan-systolic murmur
jugular venous pulse
a JVP raised by 15cm (with the patient lying at a 45° angle)
peripheral pulses
This patient has no palpable pulses in the right leg (femoral, popliteal, dorsalis pedis
and tibialis anterior). All other pulses are palpable (carotids, ante-cubital, radial etc).
HS I-II +0
normal heart sound with no murmurs
HS I
II
2/6 -- ax
1st and second HS with PSM, with m id-systolic exacerbation
grade 2 audible murmur, radiating to the axilla
RS Respiratory System
exp
TVF
PN
BS
AE
thoracic expansion on inspiration
tactile vocal fremitus
percussive note
breath sounds
air entry
Sometimes the lungs may look like this:- (these might be some of the clinical sings
associated with a R. basal pneumonia
 TVF  PN AE R.ba
Creps +++R.base
Anterior
Posterior
GIS Gastrointestinal System
Often the abdo examination is shown pictorially. The abdomen is drawn like this:-
Or occasionally, to include renal areas like this:-
It is split into nine surface anatomical areas to describe where features such as pain
or a mass may lie:Areas of pain (which the patient
feels) tenderness (which is
elicited by the examiners
palpation) or the location of
masses are usually drawn on the
diagram of the abdomen
1 R subcostal region
2 epigastric region
3 L subcostal region
4 R Flank
5 paraumbilical region
6 L flank
7 R inguinal region
8 suprapubic region
9 L inguinal region
Nb when regions on a patient are described or drawn, one always refers to the
patients left or right
LKKS
PR
PV
BS
liver, kidneys and spleen (\°LKKS means no palpable liver, kidneys or
spleen)
per rectum – rectal examination
per vaginum – vaginal examination
bowel sounds (NB BS in RS exam = breath sounds)
NS Neurological System
CN I-XII
PERLA
PTS
P2/5 etc
B,BR,KJ,AJ
P or P
VS
LT
1st to 12th cranial nerves
pupils equal and reactive to
power, tone and sensation
power is grade 2 out of 5 (range is 0 to 5)
biceps, brachioradialis, knee jerk and ankle jerk reflexes
plantar response up- or down-going
vibration sensation
light touch sensation
PR
PP
proprioception
two-point pin prick discrimination
Miscellaneous other things
CXR
AXR
PA
chest xray
abdominal xray
postero-anterior (ie xray plate in front of organ, xrays come from back
to front)
AP
antero-posterior (ie xray plate behind the organ, xrays come from front
to back)
LSS
XRlumbo-sacral spine xray
CxS
XRcervical spine xray
USS
ultrasound scan
KUB
kidneys, ureters and bladder
CT
computerised tomography (CAT = computerised axial tomography)
MRI
magnetic resonance imagery
OGD
oesophagogastroduodenoscopy
ERCP
endoscopic retrograde cholangeopancreatogram (nb ERPC =
evacuation of the retained products of conception)
BSO
bilateral salpingo-oÖphorectomy
TAH
total abdominal hysterectomy
Scolon
sigmoid colon
Hx
often a generic term for history
Ex
often a generic term for examination
Ix
often a generic term for investigations
Rx
treatment
MSU
mid stream specimen of urine
EMU
early morning specimen of urine
AFB
acid-fast bacilli
ZN
Ziehl-Neelsen stain
MCS
microscopy, culture and sensitivities
FBC
full blood count
U&E’s
urea and electrolytes
CCT
creatinine clearance test
LFT
liver function test
AST
aspartate transaminase
Alk Phos
alkaline phophatase
gGT or GGT gamma-glutaryl transaminase
RBC
red blood count
Hb
haemoglobin
WCC
white cell count
ESR
erythrocyte sedimentation rate
OD
omni die – daily
BD
bid die – twice daily
TDS
ter die sumendus – three times a day
QDS
quarter die sumendus – four times a day
Nocte
at night
Mane
in the morning
Pr n
pro re nata – when required
AC
ante cibum – before food
PC
post cibum – after food